Free athleteagents - West Virginia

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State of West VIrginia Natalie E. Tennant, Secretary of State
Building 1, Suite 157-K 1900 Kanawha Blvd., East Charleston, WV 25305 phone: 304/558-8000 email: [email protected]

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APPLICATION FOR REGISTRATION AS AN ATHLETE AGENT SECTION I: APPLICANT INFORMATION 1. Name of Applicant: 2. Residence Address: 3. Residence Phone: 4. Birthdate: SECTION II: BUSINESS INFORMATION 6. Business Name: 7. Business Address: 8. Business Phone: 9. Business Officers:
If your business is not a corporation, please list the names & addresses of the partners, members, officers, managers, associates or profit-sharers of the business. If your business is a corporation, please list the officers, directors or any shareholders having an interest of 5% Use the enter key to move to the second line for the title, then tab to address and use enter for multiple lines. and greater. a. Name: Address: Title: b. Name: Address: Title: c. Name: Address: Title: d. Name: Address: Title: e. Name: Address: Title: 10. Business/occupation engaged in within previous five (5) years:

Use enter between lines of address. If text seems to disappear, it will reappear when you tab out of the area.

5. Social Security Number:

SECTION III: EDUCATION/TRAINING INFORMATION 11. Please list any formal training
as an athlete agent:

12. Please list any practical experience
as an athlete agent:

13. Please list educational background:
Page 1

Form AAR-1w

Issued by the West Virginia Secretary of State

1/09

SECTION IV: ADMINISTRATIVE/COURT PROCEEDING INFORMATION 14. Yes No Have you ever been convicted of a crime involving moral turpitude or any felony
in any state during the past ten (10) years? If yes, please provide details.

15.

Yes

No Have you ever been sued by an athlete?

If yes, please provide details.

16.

Yes

No

Have you ever filed bankruptcy?

If yes, please provide details.

17.

Yes

No Has any surety bond on which you were covered been required to pay any money on your behalf? If yes, please provide details.

18.

Yes

No Have you ever been named in an administrative or judicial determination of false, misleading or deceptive fraudulent representation? If yes, provide details.

19.

Yes

No Have you ever had a professional license, certificate or registration denied, suspended or revoked by any other state? If yes, please provide details.

20.

Yes

No Have you ever had any sanction, suspension or disciplinary action as a result of occupational or professional conduct or conduct resulting in sanction, suspension or declaration of ineligibility of a student-athlete or educational institution? If yes, please provide details.

Form AAR-1w

Issued by the West Virginia Secretary of State

page 2 1/09

SECTION V: CLIENT INFORMATION 21. Provide the name, sport and last known team for each individual for whom you have acted as an
athlete agent during the previous five years. a. Name: Sport: Team: Name: Sport: Team: Name: Sport: Team:
Use enter between the three lines for one client, then tab to the next client.

d.

b.

e.

c.

f.

Name: Sport: Team: Name: Sport: Team: Name: Sport: Team:

SECTION VI: PERSONAL REFERENCES 22. Provide the names and addresses of three individuals who are not related to you as references.
1) Name & Address: 2) Name & Address: 3) Name & Address:

SECTION VII: OATH / AFFIRMATION State of , County of .

I, , do hereby certify under penalty of law, that the information contained herein is true, correct and complete to the best of my knowledge. I am aware that, should an investigation at any time disclose any such misrepresentation or falsification, my application could be rejected or my certification revoked by the Secretary of State.

Signature of Applicant Subscribed and sworn before me on this My commission expires on day of . Signature of Notary Public , .

(notary seal)
Form AAR-1w Issued by the West Virginia Secretary of State

page 3 1/09